Drop Off Form

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Drop Off Consent Form

Please fill out this form as completely and accurately as possible so we can get to know you and your pet(s) before your visit. If this is an emergency, or if your pet needs urgent care, please call us at 636-240-7646 for a faster response.

Date *

Name *

First

Last

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Patient's Name *

Breed *

Sex *

Age *

Color *

I hereby authorize Dr. Michael Richards, DVM and Associates to perform the following procedure(s): *

I, do hereby certify that I am the owner (or duly authorized agent for the owner) of <animal> and I give the doctors(s) of Arch Animal Hospital West full and complete authority to hospitalize, treat, and to perform any other procedure that may be useful to promote the health of <animal>, I do release the doctors(s) and Arch Animal Hospital West from any and all liability arising from treating <animal>. *

I understand and agree.

Should unexpected life-saving emergency care be required I would like the hospital staff to attempt the following life-saving measures (select one): *

Closed Chest Resuscitation. This selection authorizes us to perform all efforts and procedures deemed appropriate by the veterinarian to resuscitate your pet. This selection indicates that you authorize obtaining an airway by intubation, assisted breathing, external chest compressions, the administration of drugs and IV fluids. I acknowledge that there is no guarantee that my pet will be successfully resuscitated and that unless the need for CPR is related to a medication or anesthetic reaction that can be reversed, survival after CPR is generally less than 10%. If after 20 minutes there is no reasonable chance for success, the staff will cease further CPR.
Do not attempt resuscitation. This selection indicates that you do NOT authorize resuscitative efforts should your pet have cardiopulmonary arrest. The veterinarian is authorized to administer pain medication should the patient appear to be suffering during the transition period.

A veterinarian will attempt to call the phone numbers left above to notify you in the event of a cardiopulmonary emergency.

Owner or Authorized Agent Signature *

Clear Signature

Drop Off Form

Drop Off Consent Form

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